Mental Health and HIV, the Uncharted Territory

In the typical conversation about HIV patient care, we talk about antiretrovirals; we talk about viral loads and CD4+ cell counts; we talk about the vast constellation of HIV- and HIV treatment-related complications that can impact our patients' well-being and affect the success of their therapy. In other words, we talk a lot about our patients' physiological health. We don't talk near as much about their mental health.

But if any of us have illusions that a patient's psychological state plays anything less than a critical role in his or her HIV care, and that health care providers do not have the power to dramatically improve that state, then we're due for a little re-education. In this episode of HIV Management Today, we discuss the extent to which mental health is inextricably tied to clinical health in HIV care, and what simple steps providers can begin to take to make mental health a more prominent part of the care they provide.

Joining us for this discussion are Francine Cournos, M.D., a professor of clinical psychiatry at Columbia University in New York City, who has been working in HIV and mental health since 1983 and who speaks and writes widely on the subject; and David Fawcett, Ph.D., L.C.S.W., a therapist in Ft. Lauderdale, Fla., who has been working with HIV-infected clients since the 1980s -- and who has been living with HIV himself for more than 25 years.

We begin our conversation by talking about why there appears to be such a chasm between clinical care and mental health care in HIV.

Why Is Mental Health Ignored in HIV Care?

Francine Cournos: Mental illness has been separated from other medical illnesses. And you could understand why; mental health is on a continuum. And when you get to real mental illness, the severe forms of it, they're not that much different from medical illnesses, but they're highly stigmatized.

Even outside of HIV, if you look at the World Health Organization: It's been very frustrating for the World Health Organization to bring attention to people with mental disorders, despite many studies that show how disabling they are. For example, severe major depression is as disabling as heart failure and many other medical illnesses. But you can't get the same focus on these disorders.

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Most of your mental illnesses are also, in some sense, medical illnesses. What I mean by that is that they have many physical manifestations. Here in this country we tend to make a strong mind/body distinction, which probably is somewhat false when it comes to severe illness. So, for example, severe anxiety disorders: Your heart is beating fast; your blood pressure may go up; you're sweating. Or, for example, in major depression: You're fatigued; you can't sleep properly; you don't eat properly. There's a whole list of medical components to it.

So I think it's important to say that mental health is not apart from other medical conditions you need to think about in HIV-positive people.

Myles Helfand: Dr. Fawcett, would you concur with that? Have we divested mental health too much from physical health?

David Fawcett: I absolutely concur with that. We have made this mind/body distinction, especially in our culture, as Fran noted. And that allows a lot of providers -- and society in general -- to turn a blind eye toward some of the things that are maybe less convenient or more difficult to approach.

I think oftentimes the medical community, at least those treating HIV, tend to look at the objective data; they look at the raw values; and because of time shortages they may choose to prescribe an antidepressant or an antianxiety medication, and that's the end of it.

But, unfortunately, from the patient point of view, that's not the end of it. They get into all kinds of issues that often go unaddressed. And there is a real lack of resources for people to turn to.

This is important across the entire spectrum of HIV. It's putting people at higher risk for acquiring the virus initially: There's mood disorders, or meth addiction, or a history of trauma. And then, at every stage of the illness, from the diagnosis to beginning meds to the first opportunistic infection to overcoming stigma. Each of those presents a real opportunity for any kind of mental illness to flare, and to really complicate the entire picture. So it's really hard to disentangle mental illness from the physiological process, especially with AIDS.

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